1. Kyphoplasty and Vertebroplasty in vertebral fractures

2. Kyphoplasty and Vertebroplasty
Epidemiology of osteoporotic fractures
Natural history
Morbidity and mortality
Conservative treatment
Vertebroplasty/Kyphoplasty
How its done
Selection of patients and imaging

3. Kyphoplasty and Vertebroplasty
Results
Vertebroplasty v Kyphoplasty
Acute v Chronic fractures
Controversies
Other indications
Future developments

4. Epidemiology Radiographic
25 % in post menopausal females
40% in women > 80yrs
Age group 65 yrs+ are fastest growing segment of the population
Less common in men
Melton et al. Epidemiology of vertebral fractures in women. Am J Epidemiol 1989; 129:

5. Consequences of vertebral fractures
Sentinel sign of failing health
35-40% increase in cancer deaths
23-34% increase in mortality rates
5yr survival 61% cf. 76%
Cooper C et al. Population based study of survival after osteoporotic fractures. Am J Epidemiol 1993:137;

6. Clinical incidence Majority are asymptomatic
Loss of height and stooped posture
23-33% are painful
Over ⅔rds become manageable or asymptomatic in 6-12 weeks
Cooper C et al. The epidemiology of vertebral fractures. Bone

7. Predictors of fracture
Age
Sex
Osteoporosis
Inactivity
Smoking
20-30% are multiple
Previous fracture

8. Predictors of fracture
19.2% of females with a confirmed incidental fracture had a second fracture within one year.
24% of females with two or more fractures developed a further fracture within a year.
Lindsay et al. JAMA 2001; 285:

9. Evaluation Severe back pain Often no history of trauma
Pain is worse upright
Thoracic kyphosis
Pain reproduced by pressure over spinous process
Very rare neurological deficit
Exclude other causes

10. Evaluation Think twice! Fractures above T6
Less than 55 yrs without history of trauma
Patients with known malignancy

11. Radiographic evaluation of age of fracture
Plain films
MRI
Low signal T1
High signal T2
High signal STIR
Best indicator of age is the history.

12. Bone Scan Not as commonly used as MRI
Been show to have a 93% predictive value in vertebroplasty!
May be abnormal when MRI is normal
Maynard et al. Value of bone scan imaging in predicting pain relief in vertebroplasty. AJNR 2000;21:

13. Treatment
Pain relief
Exercise
Diet
Osteoporosis
Brace?

14. Vertebroplasty / Kyphoplasty What is it?

15. How does it work?
Structural support – but no good correlation with amount of cement injected
Thermal properties
Decompression
Placebo

16. How is it done? Usually performed under general anaesthetic
Can be performed under local
Day case procedure
Minimal invasive

17. How is it done?

18. How is it done?

19. How is it done?
Vertebroplasty
Kyphoplasty

20. How is it done?

21. Indications for vertebroplasty/kyphoplasty
Only needed in a small subset of patients
High signal on STIR.
Pain on percussion
Increased activity on bone scan
T5 and below-kyphoplasty
Timing?

22. Contraindications Infection Uncorrectable coagulopathy
Anaesthetic Risk
Neurology
Middle column compromise is NOT.

23. Complications Very few cliniccal relevant complications.
Cement extravasation 70%+
Pulmonary embolus 70%+

24. Results Vertebroplasty Kyphoplasty
Significant better pain and functional improvement than conservative treatment at 3 months.
No difference at twelve months.
Vertebroplasty patients had significantly more pain than the conservative group.
Hulme PA et al. Vertebroplasty and kyphoplasty: a systematic review of 69 clinical studies. Spine 2006:31;
FREE trial.
300 patients randomised.
Assessed at one year
SF 36 PCS
Kyphoplasty 26 33.4
Conservative 25.5 27.4
p<0.0001
Wardlaw D et al Lancet 2009;21:

25. Controversies No Benefit
A Randomized Trial of Vertebroplasty for painful Osteoporotic Vertebral Fractures
Buckbinder R et al. NEJM 2009;361:
A Randomized Trial of Vertebroplasty for Osteoporotic Spinal Fractures
Kalmes DF et al. NEJM 2009;361:
No improvement against sham procedure at 1 week, or at 1,3 or 6 months.

26. Controversies No Benefit
Previous studies – lack of blinding, lack of true sham control. Couldn’t exclude a placebo effect.
NEJM studies- randomised, blinded and a sham procedure. Buckbinder needle against lamina. Kalmes – local anaesthetic around the facet joint.

27. Problems Fracture acuity
Buckbinder: bone marrow oedema indicates an acute fracture but a detectable fracture line sufficed for inclusion.
Kalmes only used MRI or Bone scan in which fracture age was uncertain.
Both groups had to have a fracture less than a year old- most groups would use 6 weeks as an acute fracture definition.

28. Problems Enrollment
Kalmes: 1812 patients initially screened,only 131 entered into study. Most common reason – patient refusal.
Buckbinder: Needed 4.5 years in 4 high volume centres to accrue 78 patients- 141 declined randomisation.
Pain severity of groups who refused not reported.

29. Problems Control Group
Is injection of local anaesthetic around the facet joint a sham procedure?

30. Vertos II Study
Prospective randomised trial vertebroplasty v conservative treatment. 202 patients.
Results Vertebroplasty had better pain relief at one year.
All fractures less than six weeks old.
Klazen C et al Lancet 2010:376;

31. Timing
The best evidence is that the best results are achieved within 6 weeks of onset!
Rarely achievable in the UK
50% + get better within 6 weeks conservatively treated.
Philosophical when to treat.
Most fractures treated in UK > 3 months old.

32. Timing Older fractures
No randomised control trials for efficacy of treatment of old fractures.
There are trials suggesting similar success rates to acute fractures of 80% success in fractures a year or older.
Brown et al. Treatment of Chronic symptomatic vertebral compression fractures with percutaneous vertebroplasty . AJN 2004;182:

33. My protocol
Fractures less than 6 weeks old who need to be hospitilised.
Failure of conservative treatment after 3 months
Vertebroplasty for all except where middle column is involved – Kyphoplasty,
Bone scan +ve

34. Vertebroplasty v Kyphoplasty
Cheaper
Quicker
Expensive
Takes longer
Restoration of vertebral height?
Less adjacent fractures
Less cement leakage
Quality of life

35. Vertebroplasty v Kyphoplasty A review of 168 studies.
Mean change in VAS 5.68
New fracture 17.9%
Cement leak 19.7%
Mean change in VAS 4.60 p<0.001
New fracture 14.1% p<0.01
Cement leak 7.0% p<0.001
Comparison of vertebroplasty and kyphoplasty in vertebral compression fractures: a meta-analysis of the literature. Spine J 2008;8:

36. Other Uses
Tumours
Trauma
Myeloma

37. Other uses Sacroplasty Sacral insufficiency fractures
Best performed under CT guidance.

38. Developments
Calcium phosphate in young patients with traumatic fractures
Prophylaxis
Adding chemotherapy agents or radioactive isotopes to the cement in tumour

39. Conclusions
Vertebroplasty/Kyphoplasty is useful in the treatment of vertebral osteoporotic fractures although some controversy still exists.
Low morbidity
Should be considered in painful fractures over 6 weeks old.